19 year old female with arm swelling. Steven Shackford, MD FACS 2006. You are called by a RN who staffs the UVM student health clinic about a 19 y/o female on the swim team who has developed RUE swelling. You should: Set the patient up for your next available appointment—10 days hence.
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Steven Shackford, MD FACS
You are called by a RN who staffs the UVM student health clinic about a 19 y/o female on the swim team who has developed RUE swelling. You should:
college athlete with no prior medical history. She relates that since swimming practice started she has noticed increased tightness in the RUE. The day you saw her was the first time that the arm was swollen. Exam reveals a swollen RUE with blue discoloration, some dilated veins on the chest wall and normal pulses. There is no palpable cord. You should:
a) Refer the patient to Hematology.
b) Admit to the hospital and start anticoagulation.
c) Get a venous duplex.
d) Get an arteriogram.
You get a venous duplex, which shows loss of respiratory phasing and strongly suggests obstruction. You should:
Lytic therapy successfully opens the subclavian vein, but there is marked effacement at the point where the vein crosses the 1st rib. In the “stressed” position (arm extended over the head) the lumen completely disappears and the collaterals reappear. You now:
a) Tell the patient to stop swimming and give up her swimming scholarship.
b) Begin anticoagulation with heparin followed by coumadin and tell the patient to stop swimming and give up her swimming scholarship.
c) Begin anticoagulation with heparin and schedule her for a supra-clavicular 1st rib resection ASAP (this admission).
d) Begin anticoagulation with heparin and schedule her for a trans-axillary 1st rib resection ASAP.
You elect to proceed with a trans-axillary 1st rib resection, which goes well. Because of your suspicion that the patient may have chronic trauma to the vein from her swimming, you turn her supine and obtain a venogram (next slide)
Still has obstruction
SVC fills, but less intensely than
a) Quit and put the patient on coumadin.
b) Do a jugular venous turn-down to the distal subclavian vein.
c) Bypass the obstruction with 16mm ringed Goretex.
d) Attempt balloon angioplasty of the obstruction.
anterior scalene (cut)
1st rib rsn
anticoag x 3 mos
1st rib rsn
anticoag x 3 mos
anticoagulation x 3 months
obstructs with stress
1st rib resection